Provider First Line Business Practice Location Address:
1356 W BASS RIVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-789-5457
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2026